Too Big to Understand

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I just finished reading the new book about last year’s financial near meltdown, Too Big to Fail (Viking, 2009), by Andrew Ross Sorkin. The book’s several hundred pages of behind-the-scenes narrative leading up to and immediately following the collapse of Lehman Brothers in September 2008 were instructive on several levels for those of us trying to sort out the complexities of health reform. Underscored by images of some of the most prominent people in the country’s financial sector literally getting sick into their office wastebaskets, mostly due to anxiety and panic, as they worked around the clock to avert a total collapse of the financial infrastructure, the book’s lessons are replete with examples of lapses in common sense, communication, sound judgment, and (most surprising) skill. It is the skill piece that most disturbed me when I considered the amount of trust that we, as citizens, place in those who control the levers of power in our various institutions—business, finance, government, academia, and the military. It is safe to say that the skills within today’s military have soared to mountaintop levels. Likewise, business in the United States is the engine of innovation that continues to drive our fundamental economy. I am no expert on academia, but I am frequently amazed by the number of world-class scientific luminaries who are part of our universities. What about government and finance? What one learns from reading this book is that these two institutions succeeded in avoiding further disaster in 2008—despite often clumsy and ego-driven decisions (and nondecisions)—at a time when clarity, calm, and decisiveness were critically important attributes in short supply. Fortunately, there were enough grownups in select organizations to compensate for some reckless and barely competent behavior. This brings us to the institution we all care most about: our health care system. I have written at length, over the years, about the issue of trust. It’s as essential as DNA within an organization of individuals; when trust cannot be found, groups disintegrate into chaos and dysfunction. Another kind of trust, however, is equally important in building cohesion, and that is the trust we have in one another’s skills and talents—the assumption that we can count upon competence among our colleagues and managers. If trust is important within and among radiology groups and hospital departments, it is clearly important among those to whom we look to make the most important decisions regarding the structure, scope, shape, and functions of the broader health care system. The basic unease I felt while reading this book about the Treasury, Congress, Wall Street, the Federal Reserve, and other players in last year’s crisis was based on the realization that the pending reform legislation requires that we trust that the DHHS, Congress, and President Obama will function with an unprecedented level of skill in reshaping the system. Unfortunately, if Wall Street and its top-tier brokerages and investment banks are considered too big to fail, we can safely say that an institution representing nearly 20% of the country’s economy is absolutely too big to fail. It is also too big to understand, even for those of us who have been part of its fabric for many years. Trusting that politicians and their staffs have enough skill to create an elegant solution to the very real problems of our health care system is a real stretch, especially after learning about the cavalier approach that many of these same people took to the financial crisis of 2008. As we approach the witching hour when the final legislation will emerge, we need to ask ourselves this question: Do we trust that the key players have the basic competence required to get it right? If health care is, indeed, too big to understand, that is a tall order. Curtis Kauffman-Pickelle is a strategic business consultant to more than 30 imaging centers and radiology practices, and is CEO of imagingBiz, Tustin, California. He welcomes your comments at